ABSTRACT The majority of patients in the United States begin hemodialysis with a catheter. Many have immature or inadequate fistulae. At 90 days 77% of these patients are still using a catheter or a graft. The morbidity and mortality from prolonged catheter use have been well delineated. Although most of us adhere to the DOQI and Fistula First tenets, a fistula at all costs can seem counterproductive. A new paradigm is needed. The techniques described in this paper offer a novel approach to circumvent the problems of increasing catheter use and long fistula maturation times. The graft for immediate use is placed in the forearm and allows the proximal vessels to mature while providing dialysis access without a catheter. When these vessels meet maturation guidelines, or when surveillance indicates impending graft failure, a native fistula can be constructed and used in a 2-3 week period. This approach minimizes or circumvents catheter use altogether.

[Show abstract][Hide abstract]ABSTRACT: Patients with central venous occlusion who are ''tunneled catheter dependent'' are a challenge for hemodialysis access. A relatively new option for them is the hemodialysis reliable outflow (HeRO) device that can be totally implanted subcutaneously. However, patients still require a tunneled hemodialysis catheter that is used until the HeRO device is mature, 4 to 6 weeks later. Here, we describe a conversion of an existing tunneled hemodialysis catheter into a HeRO device, which was combined with a ''self-sealing'' Flixene graft. This allowed almost immediate use of the HeRO device without the need for placement of a catheter.

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